WKU Fundamentals Midterm

Functions of Skin & Risk Factors

protection, sensation, temperature regulation, excretion, and secretion

immobilization, reduced sensation, nutrition, hydration, shear or friction, vascular insufficiencies, and presence of external devices

Factors that influence hygiene practices

physical ability, usual habits, being bathed by someone of opposite sex, bathing products, and culture

complete bed bath

bath adminstered to totally depenent patient in bed

partial bed bath

bed bath that consists of bathing only body parts that would cause discomfort if left unbathed like the hands, face, axilla, and perineal area; wash back and provide back rub; for dependent patients in need of partial hygiene or self-sufficient bedridden patients unable to reach all body parts

disposable/travel bath & chlorhexidine gluconate bath

bag bath contains several soft, non-woven cotton cloths that are pre-moistened in a solution of no-rinse surfactant cleaner and emollient. The bag bath offers an alternative because of the ease of use, reduced time bathing, and patient comfort

antimicrobial agent used to reduce incidence of hospital-acquired infections on skin, invasive lines, and catheters; bath basins harbor microorganisms- air dry bath basin and do not use to store supplies. Do not use CHG wipes on face, eyes or ears. May use on the perineum area. Allow skin to dry for 30 seconds; Do not rinse off, may feel sticky. Can use CHG solution in showers- don’t rinse

assessment of skin

-smooth, warm, supple, soft, flexible, not easily broken
-elastic turgor and quick capillary refill
-assess under female breasts and male scrotum
-elderly skin is paper thin and tears easily
-assess perineal tissues and bruises in multiple healing stages
-normal reactive hyperemia vs. abnormal reactive hyperemia/blanching

hyperemic changes

when pressure is relieved, blood vessels vasodilate to restore blood flow to tissues (hyperemia = redness)

‘normal’ & abnormal reactive hyperemia

reddened skin will blanch (whiten) with pressure, then turn pink/red again when pressure is removed (light-skinned patients)

blanching does not occur with pressure; sign of deep tissue damage

Venous Insufficiency S/S

Decreased hair growth on legs and feet, Absent or decreased pulses, Thickened nails, Infection in the foot, Poor wound healing, Shiny appearance of the skin, Blanching of the skin on elevation

Peripheral Neuropathy S/S

muscle wasting of lower extremities, absence of deep tendon reflexes, foot deformities, infections, abnormal gait, and decreased or absent vibratory sensation

What do we need to remember when cleaning an uncircumcised male?

Retract Foreskin

eye cleaning and care

Clean with a washcloth moistened in water, Wear clean disposable gloves, Clean from inner to outer canthus, Use a different section of washcloth with each swipe, Hand hygiene before and after care, and Do not use CHG solution or CHG cloths for eyes, ears, or face

oral cavity in older adults

edentulous, periodontal disease could lead to systemic infection, dentures don’t always fit properly, enjoyment of food may decrease with dietary changes (affects nutritional status), decline in saliva with aging, financial limitations

Who needs frequent oral hygiene?

Secretions or crusts remain on mouth, tongue, or gums; localized inflammation or bleeding of gums or mucosa is present.

shaving male pt

Before using an electric razor, check for frayed cords or other electrical hazards. Patients prone to bleeding (low platelet counts/anticoagulants) - use a personal electric razor. Shave with the grain.

foot/nail care: diabetes

Do not soak feet- Macerated skin tears easily, often resulting with infections; don’t cut nails, file them instead. Have podiatrist cut them. Lukewarm water. Inspect daily. Dry between toes. Dry socks. Wear good fitting shoes.

documentation

record procedure(s) performed, amount of assistance provided; patient’s participation in care, skin condition (i.e., red areas, breaks in skin, inflammation, ulcerations), any additional significant findings, patient teaching if provided

Fowlers bed position

head of bed raised to angle of 45 degrees or more; semi-sitting position; foot of bed may also be raised at knee

uses: eating, nasogastric tubing insertion and suction, and promotes lung expansion

semi-fowlers bed position

head of bed raised approximately 30 degrees; inclination less than fowler’s position; foot of bed may also be raised at knee

uses: eases difficult breathing, promotoes expansion and ventilation, when pt receives gastric feeding to reduce aspiration

trendelenburg bed position

entire bed frame tiled with head of bed down

uses: postural drainage, facilitates venous return in pt with poor peripheral perfusion

reverse trendenburg bed position

entire bed frame tilted with foot of bed down

uses: infrequently, promotes gastric emptying, prevents esophageal reflux

flat (supine bed position)

entire bed frame horizontally parallel with floor

uses: patients with vertebral injuries and in cervical traction, hypotensive, sleeping

activities of daily living

eating, bathing, dressing, toileting, ambulating, and transferring

deconditioning

physiological changes following a period of inactivity, bed rest, or sedentary lifestyle

positive effects of exercise: cardiovascular

increased cardiac output, strengthened heart muscle, improved venous return

positive effects of exercise: pulmonary

increased respiratory rate & depth

positive effects of exercise: metabolic

increased metabolism, gastric mobility, & body heat

positive effects of exercise: musculoskeletal

improved muscle tone, joint mobility, & muscle mass

positive effects of exercise: activity tolerance

decreased fatigue

positive effects of exercise: psychosocial factors

improved stress tolerance & decrease in illness

walkers

standard = no wheels, lift to advance forward

roller = 2-4 wheels. pt lacks strength to pick up walker

ambulating with a walker = move walker out 12 inches. begin walking with affected leg first, then strong

canes

hold cane on strong side, NOT weak
quad cane = stronger base of support
advance cane first, followed by affected/weak, then strong

crutches

Axillary = Hand grips and height are adjustable. For short term use.
Forearm = For long term use.

Ambulating with Crutches = 2-3 finger widths under axilla. Don’t lean forward unto pads; shouldn’t touch armpit; Adjust hand grips to fit comfortably when angle of elbow is 15-25 degrees.
Routinely inspect crutch tips; replace if worn

common nursing diagnoses

Impaired Physical Mobility, Activity Intolerance, Ineffective Coping, Impaired Gas Exchange, Risk for Injury, Impaired Bed Mobility, and Acute or Chronic Pain

hemiparesis & hemiplegia

one-sided weakness

one-side paralysis

What are benefits of sitting upright in a chair? *orthostatic hypertension

it can be therapeutic and leads to deeper breathing; if PT has orthostatic hypertension and gets dizzy- set them on the side of the bed for a little bit*

Which nursing diagnoses is #1 Priority? Impaired Physical Mobility, Activity Intolerance, Ineffective Coping, Impaired Gas Exchange, Risk for Injury, Impaired Bed Mobility, and Acute or Chronic Pain

Impaired Gas Exchange

Effects of immobility & What is important to make sure is also good before you get your patient back on their feet?

Alteration in Skeletal Muscles, Body Fluids and Circulation, Venous Thrombosis, Lungs, Gastrointestinal Tract, Kidneys and Bladder, Bones and Minerals, and Skin

Bone density

For immobile patient, orient patient and family to room environment:

Bed controls, Lighting, Call light, TV controls, Thermostat, Bathroom, Closet, Communication Board, Hand sanitizer, Curtain between beds, and Water pitcher

Pressure ulcers & immobility

There is a higher risk. Use Braden Scale to assess risk for pressure ulcers. *If they have a low score they need interventions. *Intervention: nurses need to reposition the pt at least every 2 hours while in the bed

trochanter roll

Prevents external rotation of the hips when patient is supine / Keeps hips in alignment. May use sandbags that contour to the body, Used for patients who have muscle weakness  or paralysis on one or both sides of the body.

log rolling

used w pt who have experienced cervical or spinal injuries/surgery; move pt as one unit, maintaining proper alignment, in smooth continuous motion (on the count of three). Place pillows along length of patient for him to rest upon.

Tips for Protecting Patients During a Seizure

Pillow under head, side rails up, loosened clothing, bed in lowest position, privacy provided, patient in side-lying position (immediately post seizure). NEVER restrain them or put anything in their mouth.

safety risk assessment

Identify vulnerable populations most at risk for threats to safety?
How does an individual’s developmental age create safety risks?
How does the physical status of a patient pertain to his or her safety?
How does the cognitive status of a patient pertain to his or her safety?

fall risk increased when:

Advanced age, History of Falls, Incontinence, frequency, or urgency, Medications (sedatives, laxatives, diuretics) or a sedated procedure within the past 24 hours, Orthostatic hypotension, Patient care equipment (IV, chest tube, indwelling cath, SCDs), Unsteady gait, visual or auditory impairment, Cognitive impairments;  decreased level of consciousness

In the event of a fire

R: Rescue and remove pt in immediate danger

A: Activate smoke/fire alarm

C: Contain fire by closing doors and windows

E: Extinguish and/or evacuate

fire extinguisher

P: Pull pin

A: Aim low at base of fire

S: Squeeze handle

S: Sweep back and forth

chain of infection

describes progress of any infectious disease, only way to stop disease is to break a link, and it is six primary links: infectious agent/pathogen, reservoir/source for pathogen to grow, portal of exit, mode of transmission, portal of entry, susceptible host

common reservoirs (host)

humans (unwashed hands), organic matter on inanimate surfaces (BP cuff, stethoscope, bedside commode, bed rails, etc), animals, and insects

Major routes of transmission

Contact (indirect or direct), Direct (physical contact; transmission through vectors), Indirect (involves a carrier or vehicle that transfers the pathogen to a susceptible host; these include food, water, blood, and fomites which are inanimate objects such as handkerchiefs, beddings, medical and surgical equipment). Droplet transmission occurs by the direct spray of large droplets onto conjunctiva or mucous membranes of a susceptible host when an infected patient sneezes, talks, or coughs. Airborne occurs when infectious agents are carried by dust suspended in the air. 

factors affecting spread of infectious diseases

Insufficient immune system /  susceptibility (Immunocompromised), Multiple illnesses (DM, cancer, emphysema, bronchitis), Critical illness (burns, trauma, transplant, AIDS, surgery, Nutritional status (malnutrition), Immunization status, Stress, and Age

breaking chain of infection

• Breaking Link # 1: Kill the Pathogen (antibiotics are given to destroy it while it is inside of the reservoir)
• Breaking Link # 2: Prevent Contact (quarantine/isolation)
• Breaking Link # 3: Prevent Escape (cover your mouth and nose/precautions)
• Breaking Link # 4: Prevent Transmission (wash your hands/precautions)
• Breaking Link # 5: Block the Ports (covering a wound or refusing to eat suspect food)
• Breaking Link # 6: Resistant Host (immunizations)

health care-associated infections risk factors

Length of hospitalization increases exposure, Number of healthcare workers in direct contact with patient, Invasive procedures - IV catheters, urinary catheters, diagnostic tests, Antibiotic administration; Presence of Multi-drug Resistant Organisms (MDROs), Breaks in infection prevention and control; failure of healthcare workers to wash their hands

*Many costs of HAIs are not reimbursed by CMS and insurance companies

inflammation & exudates

Inflammation: Vascular responses (Vasoconstriction, Vasodilatation, & Hyperemia and increased capillary permeability, and Cellular responses (phagocytosis)

Serous drainage - clear like plasma, Sanguineous draining – blood containing RBCs, and Purulent drainage – containing WBCs and bacteria; pus; a milky appearance and thick consistency,

infectious process: four stages

Incubation period – between entrance of pathogen & appearance of symptoms
Prodromal stage – from onset of nonspecific s/s to more specific s/s
Illness stage – s/s specific to type of infection
Convalescence – acute symptoms of infection disappear

localized infection

does NOT affect whole body, pathogen is contained to one body part or organ, and s/s: foul odor, edema, purulent drainage, redness, heat/warm to touch, pain, and temporary loss of function in affected body part

systemic infection

• pathogen travels through bloodstream to entire body

• can become fatal and ex. are influenza, mono, and a cold

• s/s: fever, chills, incresed HR, RR, decreased BP, body aches, lymph node enlargement, leukocytosis, nausea and/or vomiting, fatigue, weakness, malaise, anorexia, and organ failure

laboratory data

•Complete Blood Count (CBC) with Differential
•Look for increased WBC count (Leukocytosis)
•Normal WBC level for an adult 5,000 –  10,000/mm3
•Wound ,Sputum, Throat Cultures & Gram Stain
•Blood and Urine Cultures: Look for “Positive”  •Presence of pathogen in culture results  •Presence of WBCs on gram stain •Resistant/Sensitive

Five Moments for Hand Hygiene

Before, after, and in between direct patient contact; before putting on sterile gloves, after contact with body fluids or excretions even if gloves are worn; when moving from a contaminated to a clean body area during care; after contact with surfaces or objects in the patient’s room; and after removing gloves

what are the 2 types of asepsis

medical and surgical

medical asepesis

clean technique - hand hygiene, alcohol-based hand rub, routine environment cleaning, barrier precautions, use of disposable equipment

surgical asepsis

Includes procedures used to eliminate all microorganisms, including pathogens and spores, from an object or area. Procedures that require intentional perforation of the patient’s skin (injections, insertion of IV catheters). When the integrity of the skin is already broken (trauma, surgical incision, or burns). Procedures that involve insertion of catheters or surgical instruments into sterile body cavities (insertion of a urinary catheter). Caregiver will wear a cap, gown, mask, and sterilized gloves.   

disinfection

eliminates many or all microorganisms, with the exception of bacterial spores, from inanimate objects;  Semi-critical items come in contact with mucous membranes or non-intact skin and require high-level disinfection and include endoscopes, bronchoscopes, respiratory and anesthesia equipment

sterilization

a process that destroys or eliminates all forms of microbial life; Critical Items are cleaned and sterilized; ex: surgical instruments, cardiac or intravascular catheters, implants

standard precautions tier 1

• Used to prevent and control the spread of infections.
• Applies to ALL PT’s because every PT has the potential to transmit infection
• Hand Hygiene
• Barrier precautions and appropriate use of PPE

Donning PPE

• hand hygiene

• gown-tie at neck; then waist

• mask or respirator

• eyewear/goggles over Rx glasses

• gloves- cover wrists of isolation gown

Doffing PPE

• gloves

• eyewear/face shield or goggles

• untie waist of gown then neck strings

• remove mask by un-tying top strings

• hand hygiene

transmission based precautions tier 2

• *precautions determined by pathogen’s mode of transmission

• *signs on room door

• *ante-room

• *equipment use

• *transporting pt

airborne precautions

• wear N95 mask - must be fit tested

• place in negative pressure airflow room

• high-efficiency particulate air filter

• private room

• KEEP DOOR CLOSED

• communication sign on door

 *Examples: varicella zoster (chickenpox), disseminated varicella zoster (shingles), TB, measles (rubeola), smallpox, and SARS-CoV-2

droplet precautions

For droplets greater than 5 microns: strep, pertussis (whooping cough), influenza, meningitis, and diphtheria.
Wear gown, surgical mask, and eyewear when within 3-6 ft of PT.
PT must wear a regular mask when leaving the room.

contact precaution

For use when the present pathogen can be transmitted through direct or indirect contact.
Always wear GOWN and GLOVES
Place patient in private room, or with roommate with same infection. May leave room if infectious area is covered
*Dedicated blood pressure cuff/stethoscope/thermometer stays in room.

Examples: varicella zoster (chickenpox & shingles), scabies, MRSA, Ebola virus, major wound infections, RSV in infants, MDROs (MRSA, VRE), lice, norovirus, CRE (Klebisella Pneumoniae), impetigo, Clostridium difficile, and Hepatitis A ONLY if PT is diapered or incontinent of stool.

protective isolation

For immunocompromised patients. Ex: patients undergoing stem cell transplants, tissue/organ transplant, cancer treatment, gene therapy
We are protecting the patient from us, and the outside environment…KEEP DOOR CLOSED. Place patient in room with positive air flow greater than 12 air exchanges per hour. HEPA (High-efficiency Particulate air) Filter Do not allow potential reservoirs into patient’s room (dried or fresh flowers, potted plants, fruit baskets)

psychological implications of isolation environment

psychological implications: loneliness, guilt, and feelings of rejection

isolation environment: avoid expressions or actions that convey disgust or frustration

mistakes in documentation that commonly result in malpractice include:

Failing to record health or drug information

Failing to record nursing actions

Failing to record medication administration

Incomplete or illegible records

Failing to document discontinued medications

*Guidelines for quality documentation

• stick to the facts (objective and subjective)

• short simple words and sentences

• avoid assumptions, jargon, and abbreviations

• use accurate and factual measurements

• focus on the PT

• make sure the document identifies the PT’s concerns, responses, and perspectives

Kardex

Summary of the current list of orders, treatments, and diagnostic testing for a PT.

Fidelity

Be truthful in documentation. As nurses, we keep promises by following through on our actions and interventions. Includes revising the plan as necessary to achieve client goals. We do not abandon our patient if care becomes controversial or complex.

Dietary and health history

health status, age, allergies, culture, religion, prescription meds, pt general nutrition knowledge, environmental factors

BMI

<18.5 = underweight

18.5-24.9 = normal weight

25-30 = overweight

>30 = obesity

developmental needs: infants

rapid growth and high protein needs

developmental needs: toddlers and pre-school

choking risks
small frequent meals (3 meals + 3 high nutrient dense snacks)

developmental needs: school-age

influential years; however, 17% obese

developmental needs: adolescents

increased energy needs & higher metabolic growth demands (protein, calcium, iron needs)
concerned about body image and appearance

developmental needs: older adults

• metabolic rate slows

• changes in appetite, taste, smell → decreased intake of kcals

• reduced thirst sensation → dehyrdation

• decreased peristalsis → constipation & bacterial overgrowth

• difficulty chewing, lack of teeth, dentures, oral health

• chronic illnesses affect desire and ability to eat

• fixed limited income/transportation issues

• side effects of meds → anorexia & xerostomia

• cognitive impairments → delirium, dementia, depression

Serum lab tests used for nutritional status

albumin: 3.4-5.4 g/dl (chronic illness/month)

pre-albumin: 15-36 mg/dl (acute illness/week). A more timely & sensitive indicator of protein status

retinol binding protein- 1.6-6.1 mg/dl (growth of body tissues)

transferrin- 170-370 mg/dl (protein in blood that binds to iron and transports iron throughout the body)

total protein- 6-8.3 g/dl (measures total of albumin & globulin)

Foods and drinks high in protein

eggs, meat, almonds, oats, cottage cheese, milk, greek yogurt, broccoli, lentils, peanuts/peanut butter, brussel sports

dysphagia warning signs

coughing, choking, facial paralysis, head control, posture, abnormal gag reflex, delayed swallowing, pocketing, and drooling

dysphagia complications

aspiration pneumonia, dehydration, decreased nutritional status, malnutrition, disability, decreased functional status, and increased mortality

aspiration precautions

• provide 30-minute rest period before eating

• position upright (High Fowlers)

• have pt flex head slightly to chin-down position

• frequently assess during meals

• if pt begins to cough/choke, remove food immediately

• feed slowly, smaller-size bites

• avoid distractions

• place food in stronger side of mouth

• do not rush & “restorative dining” program

• sit upright in bed for 30-60 minutes after meal

Dysphagia Diet

4 levels: dysphagia puree, mechanically altered, dysphagia advanced, and regular; thickened liquids help with swallowing

Assessing Bowel Sounds

*Anterior view of abdomen is divided by 4 quadrants
RLQ ->  RUQ ->  LUQ ->  LLU

• Absence of BS indicates decreased/absent peristalsis & lower ability of GI tract to digest/absorb nutrients.

• Creates soft and gurgling or clicking sounds.

• Requires 5 minutes of continuous listening in EACH of the 4 quadrants before determining that bowel sounds are in fact “absent.”

What diet first introduces low-fiber, easily digested foods like pasta, moist tender meat, desserts, or canned cooked fruits/vegetables?

Soft/Low Residue

Low Sodium Diet

4-g (no added salt), 2-g, 1-g, or 500-mg sodium diets; vary from no-added-salt to severe sodium restriction (500-mg sodium diet), which requires selective food purchases

Neutropenic Diet

Eliminates raw, unprocessed, fresh fruits and vegetables, drinking tap water, and emphasize well-cooked foods and appropriate food handling to reduce cross contamination; recommended for prevention of infection in patients who are immunocompromised.

Enteral Tube Feeding

Provides nutrients into the GI tract (NOT IV). When a PT is unable to ingest food through the mouth but able to digest and absorb nutrients once they enter the stomach. It is physiological, safe, and economical nutritional support. Nasogastric, Gastrostomy: PEG (percutaneous endoscopic gastrostomy), and Jejunostomy: PEJ (percutaneous endoscopic jejunostomy)

Checking placement of a nasogastric tube

3 bedside checks prior to x-ray confirmation (best way - b4 feeding):

Listen for Air, pH between 1-4, and See uncoiled tube in back of throat

After gastric (PEG or PEJ) tube is placed by the surgeon…

-expect a small amount of blood on the dressing
-wait for orders from provider prior to beginning tube feeding
-ordered either full-strength (most often) or half strength (diluted with tap water/rare)
-nurse calculates input from feeding pump
-teach family feeding and flushing before discharge
-diarrhea is most common side effect and usually gets better over time…if not the nurse may have to hold feedings and start back slowly.

Continuous Feedings

– Use an infusion pump (kangaroo pump) or gravity
– Maximum hang time 4-6 hours (open system); 24 hours (closed, ready-to-hang system)
– Usually begin feeding at full strength & at a slow rate
– Increase hourly rate (only with doctor’s order) every 8 to 12 hours if no signs of intolerance (high gastric residuals, nausea, vomiting, cramping, diarrhea)

Measuring Gastric Residual Volumes

Residual volume- the volume of enteral formula remaining in the stomach

Delayed gastric emptying – 250 mL or more remains in stomach on 2 assessments (1 hour apart) or a single GRV exceeds 500 mL

Frequency of checking residuals:
– Intermittent feedings – check residual immediately before each feeding
– Continuous feedings – check every 4-6 hours

Keep HOB elevated at a minimum of ____ to prevent aspiration?

30 degrees; 45 is even better